Provider Demographics
NPI:1134240567
Name:PERFECT TEETH - WYOMING AND CANDELARIA P.C.
Entity type:Organization
Organization Name:PERFECT TEETH - WYOMING AND CANDELARIA P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-285-6098
Mailing Address - Street 1:8501 CANDELARIA RD NE
Mailing Address - Street 2:SUITE D3
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1034
Mailing Address - Country:US
Mailing Address - Phone:505-293-2334
Mailing Address - Fax:505-293-2747
Practice Address - Street 1:8501 CANDELARIA RD NE
Practice Address - Street 2:SUITE D3
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1034
Practice Address - Country:US
Practice Address - Phone:505-293-2334
Practice Address - Fax:505-293-2747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM13981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty